Stendhal Syndrome: a Psychological Response Among Tourists

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Review Stendhal Syndrome: A Psychological *Corresponding author Response Among Tourists Swarna Datta, MSc Independent Researcher Kolkata, WB 700045, India Swarna Datta, MSc* Tel. +91 8697223295 E-mail: [email protected] Independent Researcher, Kolkata, WB 700045, India Volume 3 : Issue 2 Article Ref. #: 1000PCSOJ3125 ABSTRACT

Article History Stendhal Syndrome (SS) is a behavioral syndrome characterized by anxiety and affective Received: February 12th, 2017 and thought disturbances in response to art and often to culturally or historically significant Accepted: June 5th, 2017 places. The purpose of this review is to elucidate the clinical significance of SS and discuss Published: June 12th, 2017 the various approaches implemented towards understanding the condition. Our objective is directed towards promoting further research to understand the etiology of SS as a rare medical condition and to define other potential perspectives in its investigation. Citation Datta S. Stendhal Syndrome: A psychological response among tourists. KEY WORDS: Stendhal Syndrome (SS); Psychiatric condition; Clinical symptoms; Tourist city Psychol Cogn Sci Open J. 2017; 3(2): syndromes; Neuroaesthetics. 66-73. doi: 10.17140/PCSOJ-3-125 INTRODUCTION

Stendhal Syndrome (SS) is a rare psychiatric condition characterized by a state of dizziness, panic, paranoia or madness caused by being exposed to artistic or historical artifacts or having witnessed too many of these artworks at the same time.1 Tourism has been identified as a potential cause of the emotional processes previously reported in the clinical cases of SS. Existing studies report the occurrence of similar emotional responses among tourists after visiting geographically and culturally distinct places as has been clinically manifested in a range of tourist city syndromes, discussed in detail in this paper.2 The recurrence of symptoms across mild emotional disturbances to psychoses that occur when some people visit certain cities, has drawn the attention of various researchers seeking to investigate SS and related syndromes from the perspective of medical sciences. It is towards this objective that this paper invites for further focus on the study of SS, emphasizing on the relevance of neuroaesthetics as a promising approach to the study, by offering a review of extant research on SS, and by pointing towards new paradigms for examining such phenomenon.

AN OVERVIEW OF STENDHAL SYNDROME

SS gets its name from an avid French traveler and writer, Marie-Henri Beyle, also known to the world as Stendhal.3 Stendhal drew from his experiences of travelling across the globe in his literary creations and is quite rightly known for introducing the French with the word “tourist” through his writings. This yen for travelling had led Stendhal to a multitude of emotional experiences, and it is one particular experience of visiting Santa Croce Cathedral, Florence, Italy in 1817 that is of significance here.

Stendhal talks about how the rich culture and history that Italy unfolded to him through Copyright art stirred strong emotions in his heart. He experienced a condition which was emotionally ©2017 Datta S. This is an open ac- overwhelming and evoked in him a feeling of intense ecstasy and euphoria. The debilitating cess article distributed under the Creative Commons Attribution 4.0 condition was marked by a short episode of palpitation, dizziness, and the lack of physical 4 International License (CC BY 4.0), strength to even walk by himself. The description of Stendhal’s overpowering experience in which permits unrestricted use, his book based on the “Travel Disease” or “Art Disease” instilled the confidence in many distribution, and reproduction in tourists, who experienced anxiety and agitation during their trip to Italy, to talk about their any medium, provided the original work is properly cited. discomfort candidly.

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In 1979, an Italian psychiatrist, Graziella Magherini, followed by a sense of depersonalization and alienation. This the Chief of Psychiatry at the Santa Maria Nuova Hospital, Flor- overpowering mental state was stimulated by Sigmund Freud’s ence, Italy, examined tourists, mostly brought directly from mu- lifelong fascination with the ideas of Acropolis and the Greek seums and art galleries, admitted under emergency conditions civilization. Aside from approaching such mental states as for sudden episodes of panic attacks and mental instability. The clinical manifestations, it has been treated as a state of extreme symptoms that were commonly observed among the 106 af- disillusionment. Given the multiplicity of such reported cases fected patients were identity crisis, physical and mental exhaus- it is worth addressing the role and exclusivity of places of tion, dizziness, and hallucination. Magherini’s book entitled “La paramount beauty or aesthetic value in stimulating SS among Sindrome di Stendhahl” identifies these clinical characteristics tourists.7 There has been more recent mention of an investigation as a reaction to the deep impression cast by historically signifi- of physiological attributes by a research group in Italy, who cant characters and the rich Italian culture encountered in the are measuring clinical parameters such as heart rate, blood patients’ travels. In particular, the book also discusses agitated pressure, and respiratory rate, relevant to SS among visitors of and psychotic responses to paintings or sculptures depicting his- the historically significant, Palazzo Medici Riccardi in Florence, torical revelations or wars.3 The intense emotions experienced Italy.8 by a prominent literary figure like Stendhal in response to the rich Italian history and art, led Magherini to associate related Despite various cases of SS being documented, clinical symptoms with that of SS. it is yet to be mentioned in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental EVIDENCE OF PRE-EXISTING RESEARCH IN STENDHAL Disorders - fifth edition (DSM-5). This could possibly be due SYNDROME to the inability of such clinically reported cases to meet the parameters of dysfunction necessary to qualify as a mental Beyond the obvious and intricate psychological responses health disorder according to the revised clauses of DSM-5. Of to various socio-cultural and religious aspects of travel, there particular importance is the failure to comply with the postulate is a potential and need for investigating other physiological stating that “the impairment in personality functioning and the conditions culminating in SS. This includes an examination of individual’s personality trait expression are not better understood genetic regulation, molecular and cellular signaling mechanisms, as normative for the individual’s developmental stage or socio- biochemical pathways, and affected neural networks underlying cultural environment.”7 this and other related conditions. Existent research on the syndrome is addressed primarily from the perspectives of There have been similar records of extreme emotional neuroaesthetics and neurophysiology. responses clinically manifested as behavioural syndromes in tourists visiting places rich in art, history, and culture, which will Recently, a large number of clinically reported cases of now be discussed in the form of other tourist syndromes in the SS have been intensively discussed beginning with an instance following section. in 2005, in which Amâncio5, a Brazilian neurosurgeon, reported the case of a Russian novelist who showed the symptoms of OTHER TOURIST CITY SYNDROMES SS. In 2009, Nicholson6 wrote about an episode of paranoid- psychosis experienced by a 72-year-old following his visit to Tourist city syndromes are an intriguing aspect of study in the Florence. Published in the British Medical Journal Case Reports, sense that it is commonly associated with cities that possess this case describes the patient’s eagerness to visit the Ponte distinct cultural and religious significance, and thus hold a Veccio Bridge; and having visited the site, of his experience of special meaning for the tourists. These cities seem to precipitate disorientation and “florid persecutory ideation”. Such paranoia characteristic reactions among certain visitors by virtue of even included references to international airlines, bugging of their reputations.2 The following paragraphs provide a brief rooms, and other strange and peculiar notions. These symptoms overview of the lesser known but widely experienced behavioral gradually subsided over three weeks of physical rest. syndromes similar to SS but named after cities, in terms of tourism and metaphorical associations. In 2010, Bamforth4 published evidences of similar symptoms as concluded from the experiences of the two The Venice Syndrome is a behavioral condition psychologists, Carl Gustav Jung and Sigmund Freud, both associated with Italy, where reportedly 51 men and women from of whom had reported symptoms pertaining to SS. In his Germany, France, USA, England, and other parts of the world autobiography, Jung talked about an incident in Pompeii where attempted to commit suicide between the years 1988 and 1995.2 he was mentally and physically overwhelmed by artwork. Those who survived following the suicide attempt confessed Under the spell of such an intense experience, he lost his that their sole purpose of visiting Venice was to kill themselves senses and discontinued his journey to Rome – a destination he which, according to the studies conducted by Italian researchers, never visited, given the deeply moving impressions Europe’s was often described as the “Symbol of Death”.9 imperial structures and art left on him. Freud too, reported a similar encounter with art during his visit to the Acropolis of In a similar way, the experience of being in Rome was Athens.4 The encounter incited in him a feeling of enthusiasm found to stimulate Jerusalem Syndrome, which entails a state

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ISSN 2380-727X http://dx.doi.org/10.17140/PCSOJ-3-125 of caput mundi – a feeling of lightness associated with spiritual places in India, particularly Varanasi, Rishikesh, Auroville, and awakening.10 Even though the first medical case of Jerusalem Dharamsala, are considered significant in spiritual pursuits of Syndrome was first reported in 1930 by an Israeli psychiatrist, meditation, self-discovery, consciousness, self-empowerment, Herman11, it was not until 1970 that the clinical records of the healing, and yoga, evoking revelations about self-identity, syndrome began to be maintained by the Kfer Shaul Mental personal discovery, empowering, and healing among their Health Centre, Jerusalem. The records present a count of followers.16 The expectations of evolving as an individual and approximately 100 medical cases of Jerusalem Syndrome being discovering the true meaning of one’s identity has resulted in reported every year and 40 patients being admitted for it on the development of India Syndrome among the visitors from average. Living in the delusion of being an imaginary religious the Western world.17 An incident involving the disappearance of figure, the affected pilgrims compulsively indulged in chanting an Irish and an Australian tourist during their trip to Rishikesh sermons and Biblical verses and obsessed over cleansing of the in their quest for spiritual enlightenment drew the attention of soul, marked by continued bathing and cutting of finger and researchers.18 Consistent with the conventionally discussed toenails. Stendhal and Jerusalem Syndrome, in this case, the affected individuals showed signs of delusion, hallucinations, high blood Visits to other religious sites such as Mecca and the pressure, and increased heart rate under the burden of the social Vatican have also been known to induce similar psychedelic expectation to undergo a transformation as an individual.19 responses in tourists. One study reports an interesting medical case of a 62-year-old woman who travelled to Egypt from Israel Evidence of such behavioral anomalies caused by with her husband.12 The patient expressed anxiety, sleeplessness, religious fervors has also been noted in relation to Buddhism. restlessness, mood fluctuations, and abnormal behavior during The most unnerving of those is the incident of a Japanese the trip. She preached continuously, did not want to leave the monk setting fire to a religious building that drew pilgrims and church, offered water to other tourists by calling it wine, licked worshippers from all over the world. This incident was later the floor in her hotel room, cleaned her entourage, hit herself in adapted into a novel that based its plot in the Kinkaku-ji Temple, the stomach, and claimed that she was possessed. Investigation a famous temple in Kyoto, Japan. Though no reported cases of revealed that the patient had previously experienced a similar mental illness have been found in the pilgrims to that temple, condition 20 years ago during her visit to the Vatican and on the novel uses the theory of a Kinkaku-ji Syndrome to explain a work trip to Turkey. She was kept under surveillance in the the monk’s psychological stimulus in destroying a temple of hospital for over a month following which she was discharged religious and cultural significance.20 with a prescribed dose of psychiatric medicines and an agreement with her husband to not let her visit any other places of worship Focusing on another attribute of psychological in the future.12 condition related to travelling brings us to discuss the Airport, or Airport Wandering, Syndrome, in which the affected Besides art, history, culture and religion, syndromes individuals are found unaware of their identity or any relevant are also triggered by the otherness of a destination. The Paris details of their whereabouts. Being lost in the airport without a Syndrome is a notable but rarely discussed instance of such travel purpose is in itself symptomatic of a pre-existing mental cases. It was first reported in the French psychiatric journal, disease.10,13,21-22 Rare occurrences of similar psychological Nervure, in 2004, describing a frequently observed psychological abnormalities have been reportedly experienced by visitors in anomaly in Japanese tourists on their visit to the City of Lights.13 art galleries or museums, often indicated in their comments as The syndrome is symptomatic of extreme agitation that has led “Art Headache”, “Cultural Overload”, “Museum Fatigue” and patients to hallucinate about their hotel rooms being bugged “Cultural Overflow”.1 Evidence supports similar influences on or to consider themselves historically significant and powerful reading fictional literature and witnessing scenes of immense leaders of France. Possible reasons for the Japanese being beauty.1,23 susceptible to this condition are the stark contrast between the Parisian lifestyle with their own, unfamiliarity with the place and The stimulating relationship between the tourist and the the language, and expectations from the idealized image of Paris destination leaves a deep impact on the observer’s mind. Often, as depicted in movies and pictures. The frequency of tourists the tourist’s brain is so positively influenced by the experience affected by this syndrome has necessitated a 24 hour helpline so as to be stressed by it, thus, culminating in the clinical symp- by the Japanese embassy, which ensures immediate medical toms of the widely classified tourist city syndromes such as SS access to tourists in case of a psychological breakdown. While and the others described here.20 bedrest is a commonly suggested method for recovery in such cases, leaving the city under medical supervision may be the POSSIBLE FACTORS AND APPROACHES TOWARDS THE only option bearing positive results under critical conditions.14 STUDY OF STENDHAL SYNDROME

Asia has also captivated the attention of various Travelling is often motivated by the coming into contact with Western tourists who tend to be drawn towards “dharmic” art, history, and culture of a destination, with the expectation philosophy (religions or beliefs from India) and traditions.15 Holy that it will lead a tourist to different (and at times richer) feelings

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ISSN 2380-727X http://dx.doi.org/10.17140/PCSOJ-3-125 and sensory experiences. This motivation underlies the nature experiences worth remembering under certain circumstances of association between the tourist and the destination. Seneca24, after having observed a certain piece of art. The third variable is the Italian philosopher, once said that a tourist’s gaze is akin to “the selected fact” according to which the perception of the art a child’s wonderment at seeing the unfamiliar. For tourists with object can largely influence the reaction evoked in the observer. psychological difficulties, such wonderment and foreignness The constant in this equation is the content, the symbolism, and of travel can lead to a range of symptoms like longing for the parameters that shape the artistic value of the art object. This possessions, fits of anger, expression of love, and a burdened equation represents the distinct responses of different individuals mind. Other than a history of mental illness, individuals who are to the same artwork, or a reaction of the same individual to the psychologically fragile and overtly sensitive or emotional are same artwork at different times of his life.26 The self-explanatory also susceptible to such symptomatic behavior. equation as presented by Dr. Magherini can thereby possibly be applied towards understanding the range of distinct emotional In 1999, Hall and Page25 elucidated the importance of and psychological responses that an artwork or a tourist scholarly research towards investigating the aspect of human destination can elicit in the observer when affected by SS. motivation in tourism. They draw on Maslow’s theories of human needs and motivation to posit that travelling enabled NEUROPHYSIOLOGICAL APPROACH individuals to discover their true selves by exploring the depth of their emotions. A related classification model was developed The clinical diagnosis of multiple cases of SS was reported by by Mitchell in 1983 based on a study of nine types of people, Magherini for the first time in medical history. Her contribution such that the higher levels of the model represent the inner- towards the treatment of patients presenting with a range of emo- directed tourist who depends on travel as a means to self-reflect tional responses and behavioral anomalies created awareness and introspect. In the 1980s, McNulty identified that 38% of the and knowledge of the commonly experienced clinical symptoms tourist population in his study fell under this category. The higher among those affected by SS. On the basis of her record of treat- percentage reported in McNulty’s study indicates an interest ing such patients, she inferred that the disease had an unpredict- among the tourists which should be considered as a pathological able and unexpected onset. The symptoms lasted for about 2 to 8 predisposition only in a small percentage of people. Current days, triggered thought disturbances in 66%, affective disorders focus on Maslow’s pyramid supports the idea that on reaching in 29%, and anxiety disorders with panic attacks in 5% of the the highest level, the pyramid becomes inverted as a mirror patients. The characterizing symptoms of the affected also in- extending towards other levels of psychological needs. Thus, cluded sweating, physical weakness, tachycardia, chest tightness the unique experience of a tourist having witnessed a classic and a sense of alienation, anxiety, and confusion. Among the less tourist attraction cannot be recreated, replaced, or reproduced. commonly reported symptoms were agitation and the desire to Literature, theatre, cinema, and television also perpetuate this destroy local works of art.27 tendency by creating a collective imagination for places and experiences, and thereby presupposing tourist syndromes in Over 50% of the reported cases of SS indicated a medi- places other than those typically suspected.20 cal history of psychiatric disorders in the patients. Repressed sexual drive, fatigue, inadequate sleep, or the coming to the end It is on account of the complex emotional strain of a trip were some of the potential factors which were com- associated with tourism that researchers have been led to monly attributed to its clinical manifestation. Although, some investigate the implicit mechanisms of this phenomenon, which patients were undergoing moments of change or uncertainty, can incite such syndromes in tourists. Though pre-existing studies they were mostly psychologically sound before the onset of SS. elucidate in great detail the neurobiological and psychoanalytical A comparison of the patients with the unaffected tourists based approaches towards an understanding of SS, these also pave the on demographic and socio-cultural attributes revealed that older way for further research on other potential approaches such as mean age and lower educational qualifications were likely pre- neuroaesthetics, study of neurobiological mechanisms at the disposing factors. Among the affected tourists were a smaller level of genes and signaling mechanisms, and analysis of neural percentage of managers, businessmen, or professionals com- associations and networks across different brain areas to enable pared to healthy tourists, who mostly comprised women on an a complete understanding of SS in biological terms. unplanned trip.7

PSYCHOANALYTICAL APPROACH Guerrero et al7 investigated the incidence of SS and related symptoms in a group of neurologists by conducting a Magherini devised a psychoanalytical approach to study artistic survey during a series of professional workshops held in the cit- enjoyment as a complex association of psychological responses, ies of Rome, Florence, Padua, and Venice. The survey aimed evoked in an observer by artworks. A model equation of this to collect demographic data by interrogating neurologists about approach is defined by three variables and one constant. The symptoms they had observed in the form of positive responses first variable is “the primary aesthetic experience”, which such as aesthetic pleasure, excitement, euphoria, feeling of om- is established at the beginning of life and carried forward nipotence, or negative responses such as changes in perception, intrinsically as a mother-child aesthetic experience. The feelings of guilt, insecurity, inadequacy, or unpleasant somatic second variable is “the strangeness”, which brings back remote symptoms, and if their patients suffered from a complete or par-

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ISSN 2380-727X http://dx.doi.org/10.17140/PCSOJ-3-125 tial form of the syndrome. Of the 48 questionnaires that were been studied extensively with the exception of the functional handed out to the participants, the mean age was recorded as role of brain as the site of creation, execution, and reception 50±9 years and the male/female ratio as 1.7/1. Twenty-five per- of art. As a result, the neurological aspect of this phenomenon cent of the participants reported observing a partial form of SS still remains to be explored and examined sufficiently.39 And it without any panic attack or thought disorders, but with substan- is this gap in human understanding that has led to the founding tial response to art mainly including pleasure (83%) and emo- of neuroaesthetics. It is a concept that segments the brain as tion (62%). Crucially, none of the neurologists reported serious visual and artistic. The visual brain serves as an instrument symptoms of SS but only a partial form of the condition with of perception, which explains artistic creation and extends implications of milder clinical symptoms.7 into the artistic brain.40,41 According to Zeki42,43, the underlying assumption in this theory is that the conception and perception From the observations, it was noted that SS was more of artwork is created in the brain and therefore, aesthetic commonly associated with European tourists and rarely with characteristics are essentially neuroaesthetic. He believed Asians, Italians, and North Americans. Particularly for those that artists are neurologists who examine the visual brain living alone, belonging to a classical or religious educational through the use of various special techniques, and encouraged background have a greater tendency to develop SS.6,28 Nicholson neurobiologists to take a look at art as a useful field for analysing et al6 attributed the occurrence of SS to cultural overload, which how the brain functions and thus, demystifying the emotional evokes an anomalous autonomic reaction among the tourists. reaction to beauty in any form.26,42-44

NEUROAESTHETICS In her more recent research, Magherini analyzed SS by focusing on the constancy of the artwork and not on the Proust, a legendary French novelist and critic of the 20th century, clinical characteristics of the patients. For this study, she chose has been closely associated with medicine and neurology a sculpture of David – symbolic of young physical and mental because his asthma was considered a psychosomatic condition energy supported by heroism, sensuality and intelligence, which (neurasthenia).27 It is believed that the author was involved in has previously been known to trigger various psychological substance abuse and stimulants, and expressed a morbid fear of responses among its spectators.45 A review of the entries in the having a stroke, language and memory dysfunctions, dizziness, guest record book of the Academy Gallery in Florence, Italy, and falls.29-31 The author’s intrinsic fear was reflected in one of during the 500th anniversary of the sculpture, was undertaken. his characters who has a fatal stroke on seeing the most beautiful This exercise revealed a gamut of responses from the audience: painting in the world, which was the author’s personal favorite. while some were awed by the perfection of the masterpiece, There were also instances of the author experiencing symptoms a few pointed at the minute imperfections in the structure. A akin to those of SS, such as malaise, dizziness, tachycardia, and majority of the visitors expressed positive feelings about the transient loss of consciousness upon visiting an exhibition of artwork, marveled at its longevity, and were attracted to and Dutch paintings at the Jeu De Paume Museum in Paris.32 even enamored by the statue despite being aware of its inanimate nature. On the other extreme, some of the visitors expressed The objective to explore the neurobiological mechanism negative connotations of unpleasant experiences, painful underlying aesthetic enjoyment – a factor affected by SS – brings emotions, hostility, competitiveness, and an intense desire to to the fore the concept of mirror neurons.33,34 Studies conducted destroy the structure altogether.26 on primates, in 1996, observed that certain neurons in the frontal premotor cortex were activated in response to the execution of an In the following years of discussion on SS, related action as well as the observation of an executed action by another symptoms were reported in a population of subjects and individual.35 This finding was later also confirmed by research locations with similar characteristics such as Venice or Rome or in social behavior positing that empathy causes and defines places like Jerusalem and India – places associated with religion, response to visual interactions with art.26,36 In support of the mythology, mysticism and culture.26,46 This emphasized the physiological basis of empathy, Nietzsche, a 19th century German crucial need to understand the causes underlying these disorders philosopher, claims that “empathy with other souls is not moral, in the presence of an artwork or a place of spiritual and aesthetic but a physiological susceptibility manifested by suggestion.”37 beauty. In 1952, Kris went on to elaborate how intense emotional Freedberg and Gallese had presented a theory of empathic responses that are not otherwise expressed easily are highlighted responses towards artworks, which suggested that observations by artistic expressions. The association with art causes an of art activate mechanisms of stimulation embodying emotions, intrinsic and subtle transition in the observer of art, thereby actions, or bodily sensations. These reactions were considered forcing an outburst of suppressed emotions. The intensity of universal given their basis in neural tissue and a consistent the emotions triggered is enhanced further, depending on the exposure to various historical, social, cultural, and personal proximity between the observer and the artwork or artifact.26 factors. However, unlike the psychoanalytical approach, these factors also take into account the perception and perspective In 2014, Galleta conducted an unconventional and towards art.38 innovative approach to study the appreciation of aesthetic values of artwork through the use of social media based on Questions directed towards understanding art have the intersection of perceptual psychology, neuroaesthetics,

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ISSN 2380-727X http://dx.doi.org/10.17140/PCSOJ-3-125 and information technology. Galleta’s research indicated the CONCLUSION possibility of designing an Aesthetic Algorithm, following the analysis of the neural mechanisms associated with aesthetic The objective of this review was to highlight the clinical appreciation, which could predict the aesthetic preferences significance of behavioral conditions such as SS and other related of the perceivers and viewers.47 Based on the principles of syndromes possibly caused by similar psychosocial factors. Predictive aesthetics, this algorithm can enable the artist to Our purpose has been directed towards presenting a review of modulate the amount of ‘beauty’ in a work, to elicit a certain existent research on SS and to outline the space for the multi- emotional response among its audience.38 Predictive aesthetics is paradigmatic examination of this behavioral phenomenon. Prior a planned conditioning that can orient the aesthetic preferences studies primarily explored the principles of psychoanalysis and of the audience based on their hedonic needs and stimulation neurobiology; however, the focus of our study was to elucidate of aesthetic pleasure.48 The prediction of the artwork’s beauty the importance of other potentially promising approaches such can also enable the artists to operate according to aesthetic as neuroaesthetics which can facilitate a better understanding of precognition, thereby allowing them to influence the audience’s this rare psychological condition. preferences by modifying their art. Additionally, this could facilitate the development of aesthetic persuasion through the REFERENCES knowledge of how brain areas can be activated in response to, and appreciation of, beauty. This in turn is likely to induce reactions 1. Munsey C. 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